communication

Night shift is like a nonstop final exam. Remember how waiting for the test score was sometimes harder than studying for the test? Nights is a series of problem-solving exercises, where you have to come up with your best explanation and plan, then leave the building. You come back twelve hours later, and like it or not, the answer is up in public view. The rest of the residents and attendings on that service have had all day to think about it, and the official position is out: you got it right, or you missed this or that diagnosis or test or medication, and everyone knows.

I need a handbook, something like “Medical Spanish for Dummies,” maybe “How to Break Bad News in Three Easy Steps.” Last night was the worst test ever: a CT scan so bad I had to look at it three times before I completely realized how bad it was (and then radiology was overwhelmed, and perhaps felt I’d used up my quota of over-the-phone consults, and couldn’t read it for me till two hours after I needed it). After a few bad experiences early in the year, there’s a couple of conversations I try to avoid having with patients: being the first one to tell them they have cancer, especially as a consultant; giving bad news in the middle of the night; giving bad news without a family member available for support. So I looked at the CT another three times, to see if I could get out of it, and I couldn’t. How do you tell someone, You’re going to die within the next few days; I could try to stop it, but you really don’t want me to. And then, in the textbook scenarios, the patient is supposed to have something to say to that: questions, denial, grief – something. When they don’t say anything except, OK – you can’t even really try to comfort them, because there’s nothing left to say.

As if that wasn’t bad enough, then I felt obliged to call their family and explain the momentous decision we’d made. No one answered the phone, so I thought I had escaped at least that difficult conversation. Then, ten minutes before the end of my shift, the family got my message and called back; so I did have to tell them. I could have deferred it to the primary service (we were just consultants), or to the daylight team that I had already signed out to, but although I try not to be the one giving bad news (I think I’m still too junior to be the one making life and death pronouncements), I despise doctors who dodge their responsibility, and let days go by without telling patients and families the bad news that the medical team already knows. I was the one who’d read the scan, talked to the primary service and my attending, and had the discussion with the patient. So I talked to the family, on the phone (even worse than in person; another rule from medical school – don’t give bad news over the phone), stammering and repeating myself and hiding in a forest of medical details. They understood me, though; the only question was, how long do we have?

(And how do you answer that question, anyway? I’m in the business of trying to keep people alive. I’m not really familiar with how things go when we decide to give up. All I could do was make a guess, and warn them that I could be off by several days in either direction.)

So then I had to go home, and try to sleep, and wait to come back in the evening and find out –if the radiology attending agreed with our preliminary reading of the scan (what if I had made all these dramatic statements, and been wrong on the diagnosis?); if the surgery attending agreed with my assessment of how bad the prognosis was; if discussion with the family in the light of day changed the decision about whether to intervene or not. I couldn’t decide whether to wish that I had been flamingly, humiliatingly incorrect on all points, and the patient would do better than I thought, or that I was correct, with all that implied for patient.

I love texting on cell phones. It used to be, if you wanted to ask the chief a question, let alone the attending, you thought about it long and hard. Is this worth calling or paging them, distracting them from what they’re doing, making an incident out of the fact that I can’t figure it out for myself, or worse yet, can’t remember what they told me to do?

I’m sure for the chiefs, there was also an element of wanting to know things (how’s that patient in the unit doing; is the new admission here yet; did the attending agree with my plan to operate on this patient tomorrow), but not wanting to keep paging the junior residents repetitively for minor things.

Now we just text each other. Forget about waiting for answered pages, or spelling out your message to the operator. Text messages range from brief notes (“rounds at 8;” “meet me in OR 12;” “urine output better?”) to complex instructions and algorithms. Even some of the younger attendings have cell phones that they’re comfortable with us texting them on with brief messages, though of course not a first-time presentation of a new patient (“CT normal, will admit for pain control;” “OR got an emergency, your case is being pushed back”).

Although in general I would make a philosophical case against the rise of text messaging (it encourages communication without commitment; you want to say something, but don’t want to have to listen to the other person’s answer), in this case it dramatically improves real-time communication, and relieves stress for the junior team members, since texting is not as big of an intrusion or an admission of inadequacy as paging would be.

I guess my communication style can’t be that bad. The family involved in the conversation that inspired my last post said so many good things that the attending complimented me on it – and it has to be pretty good for an attending to go out of their way to say something positive.

Then today I was operating with the most demanding attending in the program. All the residents, even the most senior, are a little scared to operate with him, not because he’s mean, but because he has such high expectations, and doesn’t stop pressuring you. For the junior residents, being intellectually lazy, sometimes we’d almost rather not operate, than be with him. But today, I thought the comments were at a pretty minimal level, and after he left the room, the tech said, “It was so nice to have you today. Thank you for doing such a good job.” I said I thought I’d been remarkably slow, and the nurse responded, “No, compared to days with other residents, this was very smooth and quick.”

Which has given me so much job satisfaction, and no doubt a big head too, that something bad will undoubtedly happen shortly. The end of the year tends towards pride and stupidity; all the residents start to think about the new status they’ll attain in July (attending, fellow, chief, not-the-most-junior, not-the-intern), and correspondingly have far too good an opinion of themselves and their judgment. I can see it in myself and my colleagues, and yet I can’t quite stop myself from feeling extraordinarily satisfied that in less than two months I’ll be a third year resident, only one year away from fourth year, and that’s only one year away from the fifth year, and before you know it I’ll be done. . .

Before we started the third year of medical school, the clinical years, they had us do a workshop on breaking bad news. We had to (individually) tell an actor portraying a young woman that she had melanoma, and then help her deal with the shock of the diagnosis, and get her to understand a bit of the prognosis and the treatment plan. I did pretty badly, as I recall. I blurted out the news baldly, and then sat there, unsure whether to hold her hand, and unable to control the conversation enough to communicate anything else meaningful through her (very fake) tears.

I don’t know if I’m any better at it now, but it’s not for lack of practice. In surgery, there’s a lot of times when people come to see you, somehow not realizing that if they’ve been sent to a surgeon, they’re going to have surgery. Whether it’s in the office, or the ER, or a consult in the hospital, I’ve had a lot of conversations along the lines of: “We now know what the problem is, and you need to have surgery in half an hour/in two hours/tomorrow/next week. The risks of surgery include, but are not limited to, death, serious injury, abscess, wound infection, respiratory failure. Please sign the paper.”

That is of course merely an outline. Depending on how much time we have, I try to spend a little while explaining the diagnosis, and how it leads to surgery, so that it doesn’t seem like we’re recommending this out of the blue – that there is in fact a reason for the commotion. Then I explain what we’ll do during the surgery; depending on how much blood and guts is involved, I may edit this extensively. Then the consent, which always sounds bad inside my head; if somebody asked me to sign a paper accepting all those risks, I don’t think I’d cooperate.

The more of an emergency it is, the sicker the patient usually is, the less likely family members are to be handy, and the more of a rush I’m in. Usually, after calling the attending and the OR, I have half an hour to get the consent signed, have my note written on the chart, get blood drawn for type and cross, a last minute EKG if needed, antibiotics ordered (and call the pharmacy and explain that I mean now, not tomorrow), get the patient transported to pre-op holding, and a quick talk with the anesthesiologists about what we’re planning and what kind of lines might be needed. Plus answering all the other pages I’m going to get in the meantime.

So sometimes, like last weekend, it really does boil down to this (at the top of my lungs, because of course the elderly patients are all hard of hearing, more so under stress): “You have a very serious problem, and if you don’t have surgery you will almost certainly die very soon. You need to have this surgery, right now. But even if we do our best, there’s a very high risk that you will still die, or end up in the ICU, even on a ventilator, for a couple of weeks. Do you understand that? Ok, please sign.” (That was for mesenteric ischemia – dead gut, which had already been sitting around for a while. And then the nurses found the DNR papers, and I had to persuade everybody that since the patient had just insisted that they wanted to have surgery, and wanted everything done, the DNR orders were implicitly revoked, and it was ok to intubate for surgery. Why are DNRs always there when you don’t want them, and never when you need them? Fortunately for all concerned, our preop assessment turned out to be an overestimation of the seriousness of the situation, and the patient spent only one day in the ICU.)

Which is all to say that, as in my medical school days, I’m still trying to figure out how much time to spend commiserating and comforting, and when to move the conversation on to what our plans are. Sometimes it’s easier to have the pressure of the impending OR to set the timetable.

Saying “I told you so” in medicine is not very enjoyable. Usually something pretty bad has to happen for things to get there, and by that point it’s no fun knowing that you were right.

Of course, you also have to have had the guts to stand up for a while, disagreeing with the chief and the attending, in order to be able to say I told you so. Mumbling it to myself, that I would have been right, if only I’d had the courage to say out loud what I thought, is even less satisfying. I’m not good at arguing with people for days on end. Maybe when I get more confident with my judgments, and better at giving an explanation (rather than falling back on “it just doesn’t add up your way”), I’ll get better at sticking with an unpopular conclusion.

I have a knack for tripping over the elephant in the room. But I ask you, how was I supposed to know that the attending got consent for an operation, performed it, and explained the procedure to the family afterwards – without ever stating outright that the patient had cancer? I don’t know, maybe he said it and the family were too upset to hear it. But I hate trying to backpedal when I say “cancer” casually as part of my explanation of the recovery period, and the family acts as though they were still hoping the object in question was benign, or perhaps a false alarm entirely. I’m getting good at a spiel for “I don’t explain this, I don’t have a lot of experience with this, I don’t want to misinform you, my attending will explain in due course,” along with my spiel for “swelling after surgery is normal” and “use the incentive spirometer or you’ll get a fever” and “please start walking now or you won’t be able to go home.”

Most of the attendings here have a policy that they won’t discuss pathology results until the patient leaves the hospital after surgery. I can see their point, after watching families and/or patients so devastated after learning the extent of the cancer that they have no will for recovery. But then the attending isn’t the one talking to the patients and families three times a day, and trying to sidestep the only question that people really care about – what did you find, how big was it, how bad is it, is further therapy needed . . . and of course, how much time do we have. People always think they want to know the worst of it right away, but perhaps it’s not best for them to know. I’m ok with saying that I’m not the attending, so what he chooses to tell the family isn’t my responsibility; but I wish he would give me the cue card for what he did say.

You know the teamwork/collegiality concept is having a bad day when a nurse walks up and starts commiserating about how difficult it must be for you to keep on executing the attending’s unpopular plan in the face of opposition from the nurses and two or three separate groups of consultants. I fell back on the “no comment” defense. No matter what I think of the attending’s plan, as long as it doesn’t seem positively unethical, I’m not going to express my doubts to the nurses or to nonsurgeons. Besides, as far as I can tell, he’s the expert in this area, and is much more likely to be right than his detractors are.

Disclaimer

Patients described here are purely fictitious, and any resemblance to actual persons is entirely coincidental. The theology, on the other hand, is very much for real.
Please see a real live doctor for any personal medical concerns.